Provider Demographics
NPI:1598050163
Name:UTASH, JACOB MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MATTHEW
Last Name:UTASH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 MICHIGAN ST NE # MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-8242
Mailing Address - Fax:616-391-8317
Practice Address - Street 1:80 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6980
Practice Address - Country:US
Practice Address - Phone:616-391-8242
Practice Address - Fax:616-391-8317
Is Sole Proprietor?:No
Enumeration Date:2011-06-12
Last Update Date:2016-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301098739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460Medicare PIN